Common Shortcomings of Inpatient Suicide Assessment and Care

One of the most common reasons for psychiatric hospitalization is for patients determined to have an elevated risk of suicide. The goal of psychiatric hospitalization is to reduce that risk. Yet quality-assurance reviews of clinical records and analyses of litigated suicide cases reveal common shortcomings in regards to standards of care for suicide risk assessment and care. As a result, suicide is the second leading sentinel event in hospitals and remains the highest mortality concern in psychiatric care.

Understanding the Contributing Factors

To understand where these common shortcomings lay in psychiatric care, you must first examine the underlying factors contributing to current suicide rates. These include:

• insufficient hospitalization due to insurance problems
• psychiatric patients deemed more at-risk in the hospital
• inadequately trained staff (especially nurses)
• lack of in-depth analysis of suicide risk
• patients who hide their suicidal thoughts and even appear to be better before making an attempt
• no clear cut single predictor of high suicide risk
• an epidemic of physician burn-out
• protective environmental factors

These factors are coupled with the individual risk factors that each patient presents. The Joint Commission, a nonprofit organization that accredits healthcare organizations across the country, published a 2016 report titled “Detecting and Treating Suicide Ideation in All Settings” which outlined general suicide risk factors. Although each patient must be assessed for their own particular risk, this publication outlines some general risk factors that should be assessed in any treatment setting:

• mental disorders, particularly clinical depression and bipolar disorder. All patients should receive a basic suicide assessment, and those with clinical depression and/or bipolar disorder should receive special consideration
• previous suicide attempts or self-inflicted injuries
• history of significant trauma or loss, especially during childhood
• a family history of suicide
• a serious medical illness and/or severe chronic pain
• current alcohol and/or substance abuse
• social isolation
• access to lethal means coupled with suicidal thoughts

Evidence-Based Approaches

In addition to the Joint Commission update, there are other reasonable and customary evidence-based approaches for inpatient suicide risk. These include short-term, acute risk factors in particular, as opposed to the ongoing risk factors just described. These short-term risk factors include:

• panic attacks, especially occurring only recently
• constant psychic anxiety, especially if developed recently
• loss of ability to feel pleasure
• diminished concentration
• recent onset of delusions and hallucinations, especially auditory hallucinations commanding one to hurt oneself
• recent diagnosis of a life-threatening medical illness
• recently prescribed medication that can increase suicide ideation
• insomnia

These acute inpatient risk factors can be addressed rapidly by monitoring the patient more closely, prescribing anti-anxiety medication, and taking measures to improve the patient’s sleep. The use of anti-depressants and/or anti-psychotics is often indicated, but these medications require a much longer timeframe to become therapeutic. Paradoxically, anti-depressants can actually increase suicide risk if the patient develops agitation as a side effect. Lithium, however, is often effective as an adjunct in reducing suicide risk in depressive disorders.

Protective Factors

It is also important to address protective factors. These are usually unique and distinctive to each patient and therefore require an in-depth knowledge of the patient. Nevertheless, some protective factors seem to be more common than others, including:

• a religious prohibition if one is substantially religious
• a cherished animal
• significant positive relationships
• rewarding work

Unfortunately, there is no evidence that any of these protective factors can overcome acute, high-risk suicide factors in severely ill patients.

Timing

The timing of a serious suicide attempt is another complicating factor because it is often unpredictable. Most times, the best a clinician can do is appreciate any previous pattern of suicidal crises and rapidly address any acute risk factors. Even suicide attempts that were meant to be a cry for help, rather than lethal, can unexpectedly succeed.

All aspects of the suicide assessment should be documented and shared contemporaneously. One might think that a checklist of the above would suffice. It generally does not. Instead, an adequate narrative is usually necessary, including a discussion of the pros and cons of decisions. Moreover, the patient needs to acknowledge the risk assessment and provide informed consent as much as psychologically possible. The caveat is that the patient may still not share their suicide intent, a scenario that necessitates adequate suspicion on the caregiver’s part.

The clinical assessment may include suicide risk questionnaires and so-called suicide contracts. But these should only be considered supplementary information. Family, friends, and any prior clinicians may also offer valuable information. If and when a patient desires to leave the hospital prematurely or sign out against medical advice, the responsible clinician should use all ethically and legally acceptable means possible to keep the patient hospitalized, especially because the risk is often higher upon discharge.

Clinician Burn-Out

A new concern regarding suicide rates is the rising burn-out rate in physicians and other clinicians. Almost 50% of psychiatrists report burnout. In turn, burnout correlates with poorer patient outcomes. The clinical team must be able to effectively leverage their knowledge and skills; therefore, the hospital environment must pay attention to physicians’ well-being in order to ensure better patient outcomes.

Assessing and addressing suicide risk adequately is one of the greatest challenges in clinical psychiatry. In an inpatient setting, adequate risk assessment requires educated and healthy staff. Further, it requires careful coordination of staff roles, a facility with no available means to commit suicide, and attitudes and protocols that put safety first. One weak or missing link in this chain of help can result in a devastating outcome for any given patient. Psychiatrists do not currently have laboratory tests nor sophisticated technology to clearly predict suicide risk. There is no pathognomonic risk factor.

Even if clinicians follow all commonly accepted risk assessments, treatment procedures, and clinical wisdom, there is no foolproof way to predict or prevent suicide. What is possible is to meet commonly accepted, evidence-based standards of care that reduce the possibility of suicide becoming a sentinel event in the hospital. Ultimately, suicide risk assessment and care is an informed medical judgment call that incorporates information from a number of sources.